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Direction <br /> Street Number <br />StateCity <br />Ext.Land Use Application #APN # <br />Ext.BOS District Location Code <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor <br />ZipStateCity <br />Operator / Manager <br />Type of Service Requested: <br />Comments: <br />Y <br />Date:Employee #:Accepted By: <br />Employee #:Assigned to: <br />Service Code: <br />SR FORM (Golden Rod) <br />Street Name <br />Zip <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />| FACILITY ID#SERVICE REQUEST# <br />SR.®G)&Tcil42- <br />vyr <br />Type of Business or Property <br />'Uuict <br />Owner / Operator <br />ppF) <br />Facility NAME <br />City <br />^5 566? <br />Zir Code <br />ifCheck if Billing AddressJcLJ <br />Business Name <br />Phone #1 <br />(SS?) 527. <br />Phone #2 <br />( ) <br />Check if Billing Address <br />Ju,] c e. <br />Street Name <br />j Invoice # <br />Fee Amount: <br />Payment Type <br />Fax# <br /> STATE ^92^6 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STAjE and FEDERAL laws. <br />S'iDHO <br />I ■ , X <br />Home or Mailing Address _ . . . t <br />3^0(0 iaJ KJ/Glser) <br />Payment Date <br />!/ Lc <br />Site Address <br />•40M Street Number I I <br />Home or Mailing Address (if Different from site Address) <br />APPLICANT’S SIGNATURE: Date: <br />Property/BusinessOwnerB^ Operator/ Manager Other Authorized Agent <br />If APPLICANT is not the Billing Party proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the San JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. Pa <br />D4rei 4 -l(g- <br />//P'E: <br /> 7 /, <br />Received By: <br />C> <br />__________ <br />Date Service Completed (if already completed): <br />Amount Pai <br /> (check# 177^75^3